Due to a lack of targeted prevention and treatment specifically for crack use, the authors provide a comprehensive overview of secondary prevention and treatment interventions with a specific focus on crack-cocaine misuse.

Findings

Diverse Psycho-social treatment

A large body of evidence shows that psycho-social treatment (e.g. cognitive/behavioural therapy, peer-delivered interventions) can reduce drug use, as well as the negative health impacts associated with it. Though limited, it may, be the best treatment currently available for cocaine/crack.

Many studies explored pharmacotherapy treatment options for cocaine/crack-dependence, however, despite the multiple drugs tested, studies have shown no pharmacological treatments to be overall effective. At this point, the most promising options are glutamatergic and GABA (e.g. topiramate) as well as dexamphetine formulations.

Immunotherapy is considered a promising preventative-therapeutic approach, however so far the effects appear to be short lived and only in very specific populations. A new vaccine compound shows a reduction in cocaine seeking in animal studies, but it has not yet been studied in humans.

Conclusion

Even though crack use is as common as opioid and injection drug use, currently, there is no ‘gold standard’ prevention and treatment intervention for crack abuse. Further research is vital in order to develop treatments for crack/cocaine comparative to the effectiveness of other interventions such as needle exchange services and opioid maintenance treatment.

Due to the high cost of improved Hepatitis C virus treatment, in most cases, it is not feasible to offer treatment to all injection drug users at once. In order to optimize the benefits for the overall injection population, targeting HCV treatment appropriately is vital. Previously, treatment has been withheld from active injectors because of the risk that they may become re-infected and limit the benefits to themselves and the whole population.

Approach

The authors of this study look at the population-level benefits of treating one chronically HCV infected injection drug user in a population of high- and low- risk users. They then compared the benefits of treating one high or low risk user to develop an optimal treatment strategy.

Findings

High-risk injectors share injecting equipment approximately 7 times more frequently than low-risk injectors.

When approximately 32% of injectors are infected with Hepatitis C, the preventative impact of treating high and low risk injectors is equivalent

(1 high-risk injector = 1 low-risk injector).

When Hepatitis C Virus is rare, the benefits of preventing high-risk injectors spreading it to larger numbers outweighs the risk that they will become re-infected.

When the virus is already very common, fewer injectors can be infected, which reduces the spreading potential of high-risk users. At this point, it is better to focus efforts toward treating lower risk injectors who are less likely to become re-infected.

Conclusion

To enhance the preventative impact of hepatitis C virus treatment, interventions should be targeted based on how often the patient shares injecting equipment. When Hepatitis C virus is relatively uncommon among injectors, it is best to cure infected high-risk injectors. When the virus is relatively common, low-risk injectors should be targeted.

It is important for former injectors to maintain connections with syringe exchange programs (SEPs) in order to access general social and health services that will help them to maintain sobriety. This study looked at walking distance to needle exchange programs for both current and former people who inject drugs (PWID).

Approach

The study surveyed 137 people who inject drugs who presented for services at syringe exchange program (SEP) mobile distribution sites in Washington DC.

Findings

Active and non-active injectors do not have equal access to syringe exchange program (SEP) services.

Those who are not actively injecting may have less motivation to travel to access services compared to when they were actively injecting and seeking sterile equipment.

Non-active injectors may also be seeking healthcare services elsewhere.

Challenges to enhancing access to SEP services include policies that restrict where needle exchange programs can legally operate (e.g. certain proximity to schools). Future work should explore enhancing access in areas of greatest need.

Conclusion

Providing comprehensive services for former/non-active substance users, a vulnerable population, is important for addressing their complex medical and social health care needs such as addiction treatment and support and housing.

The role of peer helpers came out of a need to address the limitations of the traditional “provider-client model.”

Mediators or Peer Helpers act as both secondary distribution agents and advocates. They have become a valuable component of the most successful strategies aimed at injection drug using communities as they bring the reality of the lives of marginalized populations into strategic discussions.

This study aimed to explore the difficult situations peer helpers may find themselves in when they attempt to implement harm reduction practices and balance potential serious health problems and even death against anticipated backlash from users, medical staff, and the community.

Approach

A series of focus group sessions were conducted with peer helpers over a two-year time frame in Cape Breton, Canada.

Findings/Key Themes

Officially sanctioned peer helper practices

Overall, few moral dilemmas arose with the official distribution part of the peer helper role unless there was a shortage of supply.

Peer helpers viewed education of new users as a very important part of their harm reduction role. They felt that the hidden nature of injecting left them responsible for “how to” training.

Contrary to public discourse, peer helpers attempt to dissuade individuals from taking that first hit. However, they were exposed to threats from others such as neighbours and child protection workers because of how their role is perceived by the general public.

Peer helpers can be credited with the high rates of safe needle disposal. They play a key role in developing and reinforcing return practices.

Unofficial peer helper practices

Given that peer helpers are viewed as authorities on safe injection within their community, one of the first ways they can be drawn into an unofficial role is through requests for assistance.

The imminent threat of death from overdose is on the top of the minds of peer helpers, not the threat of blood-borne pathogens.

Peer helpers are the ones who typically step in to deal with overdose and will usually make the call to emergency services despite repercussions from health professionals and police as well as the users themselves. As a result, peer helpers find themselves caught in the middle of competing courses of action – do they call the police or not?

Due to users’ hesitation to seek medical treatment, peer helpers find themselves treating wounds and abscesses. Some helpers find themselves saving and sharing antibiotics (even though they know it’s problematic) to help those who refuse to seek medical attention.

Many peer helpers also take on the role of counselor

Peer helpers lived experience enables them to empathize with those struggling with addiction – “they almost never give up on people.” They let people who were homeless come to their homes for food, a shower and a night’s sleep.

Conclusion

Peer helpers find themselves in difficult situations with user populations often because people who inject drugs feel undeserving of services and discriminated against when they do seek services. This adversely impacts users, and particularly the peer helpers seeking to assist them. In an effort to keep users alive, peer helpers engage in practices that extend far beyond their roles of disseminating sterile syringes and safe injection materials.

Population size is a key factor in modeling of cost-effectiveness analysis and resource allocation, yet there is no gold standard method of estimating the size of “hidden” populations such as people who inject drugs (PWID) and there is no ideal method for all drugs and settings. Chronic hepatitis C virus (HCV) infection is high (approximately 50%) in current PWID. Due to the development of effective treatment for hepatitis C virus (HCV) there is growing interest to understand how increased treatment uptake will impact the burden of HCV.

Findings:

Direct methods use data from general population surveys asking people about their drug use.

Advantages: accurately estimates prevalence when the population is representative and people honestly disclose drug use.

Disadvantages: 1) relies on household surveys so excludes people who are homeless or in unstable housing; 2) if contacted, PWID may be reluctant to disclose injection drug use.

Disadvantages: linked data sources can introduce biases that are difficult to disentangle (such as cross-references between criminal and health data sources).

In England, approximately 85% of HCV occurs in current or former PWID. This was estimated through indirect methods and has resulted uncertainty in the number of PWID carrying HCV antibodies. Separating out different populations of PWID is complex, but it is critical for prevention and prioritization of treatment.

In order to assess transmission of HCV, it is important to define current/recent PWID from former PWID. However, this is difficult due to the relapsing nature of drug dependence it is difficult to determine a cutoff for permanent vs. short term quitting of injection drug use.

In order to assess impact of interventions on HCV transmission and prevalence, it is key to have information on the coverage and duration of time PWID are in OST and NSP.

Approximately, 41% of current PWID populations in Australia spend time in OST and 12% in prison. The high HCV incidence of HCV in prisons and high rates transitioning between prisons and communities is also important in designing HCV treatment as prevention and estimating population size and effects.

Conclusion

In order to develop appropriate public health policy and services to people who inject drugs (PWID), the ability to estimate current and former PWID populations is vital for both HCV treatment and prevention in new and existing measures such as opioid substitution treatment and needle and syringe programs. Improving epidemiological data on people who inject drugs is key for increasing the effectiveness of future interventions

Due to unemployment and poverty, street-involved youth may turn to risky activities such as sex work, salvaging/recycling, squeegeeing car windows for donations, panhandling, drug dealing, theft and other criminal activities to generate income. The authors used a prospective cohort design (2005 – 2012) to study risky employment of street-involved youth in Vancouver.

Street-involved: recently homeless or having used services designated for street-youth in the last year.

Findings:

Of the 1008 participants during the 6-year study, 735 (73%) reported engaging in risky income generation activities at their baseline study visit, and 826 (82%) participants reported engaging in risky income generation activities at some point during the study period.

Those with intense addition such as binge drug use, injection drug use, and drug overdose were more likely to engage in risky income generating activities. Since this finding is substantiated in previous research, reducing the intensity of substance use may be an opportunity to reduce risky income generation.

A sub-analysis of 825 participants found that 63% mentioned “dealing drugs” as an income generation activity.

Approximately 53% (n=440) said they would be willing to give up a source of risky income if they were not using drugs. The need for income to fund drug ongoing drug use is a key factor perpetuating risky income generating activities.

Youth who recently attended addiction treatment were significantly more willing to give up their risky income generating activities if they did not use drugs.

Still, a large proportion, 47%, said they would persist with their risky income sources regardless of substance use. Based on this, we know that substance use is not the only factor pushing youth to engage in risky income generation.

The role of age in influencing substance use and income generation trajectories should also be explored as the authors found older age to be associated with willingness to give up risky income sources.

Income assistance programs in the current study setting have high barriers to access and do not provide adequate financial support to meet basic survival need.

Overall, there is limited availability and access to economically sufficient legal income sources in the participant’s environment. This highlights the need to explore ways to reduce the economic vulnerability of youth.

Conclusion

The high prevalence of risky income generating activities among street involved youth, particularly those who use drugs, highlights the need for policy-makers to address deficiencies in accesses to timely addiction treatment for youth. However, the large percentage of youth who still intended to participate in risky income generation activities suggests a need to evaluate structural interventions to target the economic vulnerability of youth.

The number of licensed security guards in British Columbia has doubled in the last decade. Currently, there are 17,000 licensed security guards in the province, which is twice the number of police officers. Security guards are often hired to patrol areas frequented by people who inject drugs (PWID) such as Vancouver’s Eastside. Recent qualitative research found that people who use drugs in this area are often subject to discriminatory surveillance and abuse by security guards. As well, previous findings suggest that security guard presence may prevent access to health care services.

Findings:

One third of the sample reported at least one encounter with a security guard in the course of the 8-year study.

Of the 1172 reported encounters with security guards, participants most commonly reported that they were told to move on (70.6%); verbally abused (15.6%); assaulted (7.6%); detained (5.4%); or chased (5.1%) by security guards.

People who inject drugs (PWID) who have encounters with security guards were generally marginalized on several markers of vulnerability and drug related harm such as unstable housing, experiencing violence, non-fatal overdose, syringe sharing, public injection and inability to access addiction treatment.

Security guards may be overstepping their legal authority when interacting with people who inject drugs, such as controlling access to public space and using excessive force.

The authors found an association between security guard contact and high-risk drug use behaviours, which aligns with previous research. For example, intensified police presence has been shown to promote rushed injections, hinder access to sterile injection equipment from harm reduction services, which could contribute to syringe sharing.

Interaction with security guards was positively associated with inability to access addiction treatment, which was also found in a previous study.

Conclusion

Accounts of specific interactions with security guards suggest that reforms need to be made to ensure that security guards do to not overstep their legal boundaries in their interactions with people who inject drugs. Broader structural interventions are required to assess risk and harm for people who inject drugs in public spaces.

Kennedy, M.C., Milloy, M.-J., Markwik, N. et al. (2016). Encounters with private security guards among people who inject drugs in a Canadian setting. International Journal of Drug Policy. 28:124-127.

Risk Environment Model: addresses social situations, structures, and places that generate vulnerability to HIV transmission and other drug-and HIV-related harms among people who inject drugs (PWID).

Participant population
The sample included 9170 people who inject drugs from 15 states across the United States.

Findings:
– Across all measures black PWID were more likely than white PWID to live in areas associated with vulnerability to HIV and poorer outcomes for those living with HIV.
– Black PWID lived in more socially and economically distressed areas, had poorer access to substance abuse treatment, experienced greater exposure to drug-related law enforcement, were isolated in environments that lacked ethnic diversity and were more likely to experience the combination of hyper segregation and concentrated poverty.
– Black PWID participants tended to live in states with laws that did not facilitate access to sterile syringes (where a prescription was required for purchase and possession of syringes). Laws restricting syringe access are connected with higher HIV prevalence. Laws limiting sterile syringe access may exacerbate racial/ethnic disparities in HIV prevalence.
– Interestingly, the authors found a tendency for a law and order approach in states where people who misuse substances are more likely to be thought of as black and a more public health approach where people who misuse substances are thought to be white.
– Black PWID had better spatial access to HIV testing than white PWID, yet they had worse access to substance abuse treatment. The US public health system made an effort to increase HIV testing amongst black adults; the authors suggest that similar initiatives are needed to increase access to substance abuse treatment as well.
– The authors encourage those outside of the US to explore the “racialized risk environment” in their own countries. Previous studies have found large disparities in HIV prevalence in Canada among First Nations, the ethnic minority PWID, vs. the ethnic majority PWID. This may result from systematic differences in exposure to high-risk environments that perpetuate social inequality.

Conclusion
The environments of people who inject drugs appear to be racialized in the US. Future research should assess risk environments in other countries.

Cooper, H.L.F., Linton, S.L., Kelley, M.E. (2016). Racialized risk environments in a large sample of people who inject drugs in the United States. International Journal of Drug Policy. 27: pp.43-55.

Background
Understanding the social factors associated with the spread of HCV and HIV amongst people who inject drugs (PWID) continues to be a key goal of public health research.

Overall Study Objective
The authors examine multiple drug use episodes for each participant to gain an understanding of individual variation of injection risk behavior.

Participants
The study included a total of 835 injection drug user participants who provided data for up to 4 injection episodes.

Findings:

Participants injecting with sexual partners or non-first time partners were more likely to engage in risk behavior. There is a positive association between sexual partnership and injection risk behavior for both males and females.

Association between sexual partnership (y=1.14, p=0.014) and risk behaviour was significantly more positive for female injectors than for males.

Female-female injection partners and females with sexual injection partners tended to have higher levels of injection risk behavior in comparison to male-male injection partnerships. The authors suggest that this may be due to the norms surrounding female-female injection and/or skill and resource imbalance (previous studies have found that females have lower level of access to equipment and less experience self-injecting).

It is the specific injection event that is related to a higher risk for females. For example, a female’s sexual partner may be the one who obtains the drugs and may subsequently obtain greater control over the injection process, such as injecting first and then passing the equipment to the female sexual partner.

Authors found that size of injection network may have little effect on injection risk behavior. However, this finding may be due the inherent difficulty of participants recalling the number of injectors in the “same place and time” in the previous six months.

Interestingly, authors found significant within person variability in injection risk behavior across injection episodes (13.2% of unexplained variability). Based on this, the authors suggest that partner and setting characteristics are important factors in determining risk behavior for specific drug use episodes.

Conclusion
Gender continues to be a key factor in the association between partner characteristics and risk behavior, which may be due to resources imbalances or gender norms that may enhance the potential risk of sexual partnerships for female injectors. Interventions could target these relationships to increase communication and promote self-efficacy to reduce risk behavior.

Background
Hepatitis C Virus prevalence in people who inject drugs (PWID) ranges from 40%-90%. The volume of residual fluid within syringes depends on needle size and length, amount of space remaining in the hub of the syringe once the needle is attached and if the needles are detachable from the syringe barrel. Although they retain the least volume, syringes with fixed needles are not always acceptable to people who inject drugs (PWID). This has lead to the development of detachable needle-syringe combinations to reduce dead space.

Findings

The 1ml insulin syringes with fixed needles were the most effective at reducing HCV retention in syringes.

This remained the case whether HCV recovery was assessed immediately after use, after storage at room temperature, or after rinsing with water.

Authors found that Noloss low dead space (LDS) syringes with standard needles and the standard Nevershare syringes with Total Dose LDS needles retained levels of viable HCV comparable to high dead space (HSD) immediately after use.

Specific recommendations cannot be made for any one LDS syringe-needle combination over the others or in place of od HDS syringes due to inconsistent patterns across the three experiments (immediate testing, storage, and rinsing with water).

At this time, lower dead syringes cost more without providing much benefit, therefore economically, there is no benefit to recommending them as an HCV prevention measure.

Summary
People who inject drugs who use syringes with larger volumes and detachable needles need to be made aware that they are at increased risk for HCV transmission compared to fixed needle syringes if injection equipment is reused. This applies even when using two part low dead space (LDS) syringes and after several rinses with water. HCV prevention should focus on traditional harm reduction approaches such as preparing drugs and injecting them only with new, sterile equipment, minimizing contamination of injection locales, and hypochlorite bleach disinfection. Further research is needed on the overall impact of syringe type on HCV transmission among people who inject drugs.